1. Common Pediatric Foot Deformities
Steve Min M.D.
PGY-1
May 2002

2. Anatomy/Terminology 3 main sections Hindfoot – talus, calcaneus
Midfoot – navicular, cuboid, cuneiforms
Forefoot – metatarsals and phalanges

3. Anatomy/Terminology 2. talocalcaneal (subtalar) – inversion/eversion
Important joints
1. tibiotalar (ankle) – plantar/dorsiflexion
2. talocalcaneal (subtalar) – inversion/eversion
Important tendons
1. achilles (post calcaneus) – plantar flexion
2. post fibular (navicular/cuneiform) – inversion
3. ant fibular (med cuneiform/1st met) – dorsiflexion
4. peroneus brevis (5th met) - eversion

4. Anatomy/Terminology
Varus/Valgus

5. Calcaneovalgus foot

6. Calcaneovalgus foot ankle joint dorsiflexed, subtalar joint everted
classic positional deformity
more common in 1st born, LGA, twins
2-10% assoc b/w foot deformity and DDH
treatment requires stretching: plantarflex
and invert foot
excellent prognosis

7. Congenital Vertical Talus
true congenital deformity
60% assoc w/ some neuro impairment
plantarflexed ankle, everted subtalar joint, stiff
requires surgical correction (casting is
generally ineffective)

8. Talipes Equinovarus (congenital clubfoot)
General
- complicated, multifactorial deformity of
primarily genetic origin
- 3 basic components
(i) ankle joint plantarflexed/equines
(ii) subtalar joint inverted/varus
(iii) forefoot adducted

9. Talipes Equinovarus (congenital clubfoot)

10. Talipes Equinovarus (congenital clubfoot)
B. Incidence
- approx 1/1,000 live births
- usually sporadic
- bilateral deformities occur 50%
C. Etiology
- unknown
- ?defect in development of talus leads to
soft tissue changes in joints, or vice
versa

11. Talipes Equinovarus (congenital clubfoot)
D. Diagnosis/Evaluation
- distinguish mild/severe forms from other disease
- AP/Lat standing or AP/stress dorsiflex lat films
E. Treatment
Non-surgical
- weekly serial manipulation and casting
- must follow certain order of correction
- success rate 15-80%
Surgical
- majority do well; calf and foot is smaller

12. Talipes Equinovarus (congenital clubfoot)

13. Pes Planus (flatfoot) General
- refers to loss of normal medial long. arch
- usually caused by subtalar joint assuming an
everted position while weight bearing
- generally common in neonates/toddlers
B. Evaluation
- painful?
- flexible? (hindfoot should invert/dorsiflex
approx 10 degrees above neutral
- arch develop with non-weight bearing pos?

14. Pes Planus (flatfoot)

15. Pes Planus (flatfoot) C. Treatment (i) Flexible/Asymptomatic
- no further work up/treatment is necessary!
- no studies show flex flatfoot has increased
risk for pain as an adult
(ii) rigid/painful
- must r/o tarsal coalition – congenital fusion or
failure of seg. b/w 2 or more tarsal bones
- usually assoc with peroneal muscle spasm
- need AP/lat weight bearing films of foot

16. In-Toeing General - common finding in newborns and children
- little evidence to show benefit from treatment

17. In-Toeing B. Evaluation - family hx of rotational deformity? - pain?
- height/weight normal?
- limited hip abduct or leg length discrepancy?
- neuro exam
C. 3 main causes
(i) metatarsus adductus
(ii) internal tibial torsion
(iii) excessive femoral anteversion

18. In-Toeing metatarsus adductus - General medially deviated midfoot
normal hindfoot,
medially deviated
midfoot
diagnosis made if
lateral aspect of foot
has “C” shape, rather
than straight

19. In-Toeing metatarsus adductus - Evaluation ankle motion
should have normal
ankle motion
assess flexibility by
holding heel in
neutral position,
abducting forefoot

20. In-Toeing metatarsus adductus treatment
- if flexible, stretching; Q diaper change, 10 sec
- if rigid, or if no resolution by 4-8 months,
refer to ortho
- prognosis is good: 85-90% resolve by 1yr

21. In-Toeing (ii) Internal Tibial Torsion usually presents by walking age
knee points forward,
while feet point
inward

22. In-Toeing (ii) Internal Tibial Torsion Treatment
- reassurance! spontaneous resolution in 95%
children, usually by 7-8yrs
- controversy with splints, casts, surgery

23. In-Toeing (iii) Excessive Femoral Anteversion both knees and feet
point inward
presents during early
childhood (3-7yrs)
most common cause
of in-toeing

24. In-Toeing (iii) Excessive Femoral Anteversion int rotation 70-80 deg
ext rotation deg
“W” position

25. In-Toeing (iii) Excessive Femoral Anteversion increase in internal
rotation early with
gradual decrease

26. In-Toeing (iii) Excessive Femoral Anteversion Treatment
- no effective non-surgical treatment
- surgical intervention usually indicated if
persists after 8-10 yrs and is cosmetically
unacceptable or functional gait problems
- derotational osteotomy

27. References Hoffinger SA. Evaluation and Management of Pediatric
Foot Deformities. Pediatric Clinics of North America
43(5):
Yamamoto H. Nonsurgical treatment of congenital clubfoot
with manipulation, cast, and modified Denis Browne splint.
J Pediatric Ortho (4):
Sullivan JA. Pediatric flatfoot: evaluation and management.
J Am Acad Orthop Surg (1): 44-53
Dietz FR. Intoeing-Fact, Fiction and Opinion. American
Family Physician (6):
Canale. Campbell’s Operative Orthopedics, 9th ed. 1998 ;